COPD

Question 1

Pathology

Answer 1

Emphysema is irreversible airway obstruction

COPD = emphysema + chronic bronchitis

Question 2

Long term management

Answer 2

Patients should have the pneumococcal and annual flu vaccine.

STEP 1:

Short acting bronchodilators: beta-2 agonists (salbutamol or terbutaline) or short acting antimuscarinics (ipratropium bromide).

STEP 2:

If they do not have asthmatic or steroid responsive features they should have a combined long acting beta agonist (LABA) plus a long acting muscarinic antagonist (LAMA). “Anoro Ellipta”, “Ultibro Breezhaler” and “DuaKlir Genuair” are examples of combination inhalers.

If they have asthmatic or steroid responsive features they should have a combined long acting beta agonist (LABA) plus an inhaled corticosteroid (ICS). “Fostair“, “Symbicort” and “Seretide” are examples of combination inhalers. If these don’t work then they can step up to a combination of a LABA, LAMA and ICS. “Trimbo” and “Trelegy Ellipta” are examples of LABA, LAMA and ICS combination inhalers.

In more severe cases additional options are:

• Nebulisers (salbutamol and/or ipratropium)
• Oral theophylline
• Oral mucolytic therapy to break down sputum (e.g. carbocisteine)
• Long term prophylactic antibiotics (e.g. azithromycin)
• Long term oxygen therapy at home

Question 3

What are the indications for long term oxygen therapy in COPD?

Answer 3

Long term oxygen therapy is used for severe COPD that is causing problems such as:

• chronic hypoxia
• polycythaemia
• cyanosis: oxygen sats less than 92% on RA or pO2 <7.2
• heart failure secondary to pulmonary hypertension (cor pulmonale): peripheral oedema, raised JVP

It can’t be used if they smoke as oxygen plus cigarettes is a significant fire hazard.

Question 4

Investigations for COPD Exacerbation

Answer 4

ABG as it is important to distinguish the type of respiratory failure:

• Low pO2 indicates hypoxia and respiratory failure
• Normal pCO2 with low pO2 indicates type 1 respiratory failure (only one is affected)
• Raised pCO2 with low pO2 indicates type 2 respiratory failure (two are affected)

Other investigations:

• Chest xray to look for pneumonia or other pathology
• ECG to look for arrhythmia or evidence of heart strain (heart failure)
• FBC to look for infection (raised white cells)
• U&E to check electrolytes which can be affected by infection and medications
• Sputum culture if significant infection is present
• Blood cultures if septic

Question 5

COPD diagnosis

Answer 5

Diagnosis is based on clinical presentation plus spirometry

FEV1/FVC radio <0.7